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End-of-Life Care Conversations
This document discusses best practices for delivering bad news to patients and their families in a compassionate manner. It begins by having attendees reflect on their own experiences delivering bad news. The goal is to educate healthcare providers on how to communicate bad news effectively in order to positively influence patient and family reactions. It then discusses various methods and protocols for delivering bad news, including preparing, sharing the information clearly and slowly, and caring for the patient emotionally. Common patient reactions are explored, as well as tips for handling special situations. The document emphasizes allowing patients to process the news at their own pace and maintaining a supportive presence.
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End-of-Life Care Conversations
- 1.
- 2. Your Experiences How manyhave delivered bad news to someone in any setting outside of a medical one? • Was it unexpected? How many have delivered bad news to someone in a setting related to your clinical position? • Were you prepared for it?
- 3. Goal To educate healthcareproviders on how to communicate bad news compassionately and effectively in order to positively influence the reactions and resulting attitudes of patients and their family members
- 4. Objectives • Define “badnews” • Discuss importance of delivering bad news well • Identify three keys in communicating bad news and effectively demonstrate them • List “typical” responses to bad news and differentiate between helpful and unhelpful responses • Discuss how to handle special situations that may arise upon receiving bad news • Explore ways to break bad news by phone
- 5. Types of BadNews • A young father learns he has Lou Gehrig’s disease • A singer is diagnosed with cancer of the larynx • A teenager has only a couple of months left to live • A pregnant woman’s ultrasound confirms a dead fetus • A breast cancer survivor learns that the cancer has come back with a vengeance
- 6. End-of-Life Care Conversations areDifficult Because… • Unable to deal with intensity of response • Fearful of reaction • Don’t want to take hope away from patient • Illness as an indication of failure • The task is unpleasant
- 7. End-of-Life Care Conversations areDifficult Because… (Cont.) • Lack of training • Stress • Feeling of inadequacy • Requests by family to withhold information • Delivering bad news will take time • Personal fear
- 8. • Timing • Life/workdisruption • How the news is broken • Prior experience Context Influences Reaction
- 9. Definition “Any news thatdrastically and negatively alters the patient’s views of her or his future” —Robert Buckman “A threat to a person’s mental or physical well- being: the upset of an established lifestyle” —J. T. Ptacek
- 10. The “Truth” aboutBad News • Bad news cannot be turned into good news • The gap between the medical reality and the patient’s expectations defines “how bad” the news is • The news is considered “bad” from the perspective of the giver, receiver or both Everyone is part of this process!
- 11. Why is ThisImportant? • Patients have the right to know • It’s your job • Informed consent for further care • Most of them already know or suspect
- 12. Why It Needsto be Done Well • It’s a traumatic event • It sets the stage for Care Plan decisions • It can result in negative psychological consequences • Successful delivery can result in: – Decrease in patient anxiety and depression – Increase in healthcare worker’s satisfaction It’s about quality of life for everyone!
- 13. Remember Many patients andfamilies remember more about how bad news was communicated than anything else about their care
- 14. Bad News Communication Methods ABCDEProtocol • Advance preparation • Build a therapeutic environment/relationship • Communicate well • Deal with patient/family reactions • Encourage and validate emotions
- 15. Bad News Communication Methods(Cont.) SPIKES Protocol • Setting and listening skills • Patient perception • Invitation • Knowledge • Explore emotions and empathize • Strategy and summary
- 16. Bad News Communication Methods(Cont.) Buckman Six-Step Protocol 1. Getting started 2. Finding out how much the patient knows 3. Finding out how much the patient wants to know 4. Sharing the information 5. Responding to the patient’s feelings 6. Planning and follow-through
- 17. Three Keys toCommunicating Bad News Well 1. Prepare 2. Share 3. Care
- 18. Prepare • Plan whatwill be discussed • Allow for adequate time • Location, location, location • Find out: – How much the patient knows – How much the patient wants to know
- 19. Prepare (Cont.) • Befamiliar with all relevant clinical information • Rehearse what you will say • Family/friend present if possible • Foreshadow the bad news • Prepare yourself for strong emotional reactions!
- 20. Share • Break thenews gently and slowly • Communicate the information clearly in small doses • Wait for a response • Allow the patient his/her feelings
- 21. Share (Cont.) • Acknowledgepatient’s emotions • Ensure retention • Clarify understanding • Encourage questions
- 22. Care • Respond withcaring and sensitivity • Provide reassurance • Actively listen • Discuss options • Be available for follow up
- 23. Common Responses to BadNews • Tears • Anger • Sadness • Love • Anxiety • Relief • Denial • Blame • Guilt • Disbelief • Fear • Loss • Shame • Intellectualization • “Fight or Flight” • Leaving the room • Withdrawal
- 24. Common Patient Reactions Helpful •Denial • Anger • Crying • Fear • Bargaining • Realistic hope • Humor Unhelpful • Guilt • Pathological denial • Prolonged rage • Collapse • Anxiety • Unrealistic hope -“Impossible quest”
- 25. What if… The patientseems completely unprepared? • Clarify what the patient understands • Identify other family members or friends upon whom the patient relies Language is a barrier? • Use an experienced translator when needed • Brief translator before the interview • Avoid using family members as primary translators Your efforts are ineffective? • Schedule another meeting
- 26. What if… (Cont.) Patient/familymember gets angry/starts crying? • Remain calm and supportive The patient doesn’t understand? • Be patient. May not be able to comprehend the information at that moment—try rewording your statements to clarify Someone begins to “act out” dangerously? • Remove yourself from the situation • Call friend, neighbor and team manager You are asked about prognosis? • Talk in terms of quality of life but suggest they get affairs in order
- 27. What if… (Cont.) Thepatient is a child? • Parents may not want the child to be told about illness However: – Child may perceive there is a problem due to all the interventions – As a result, child may feel distrustful and misled • Ensure psychosocial support for child and family
- 28. What if… (Cont.) Thefamily says “don’t tell?” • You may feel caught between obligation to obtain informed consent and maintaining a congenial relationship with family • Do ask clarifying questions • Some situations may require significant negotiation
- 29. Cultural Sensitivity • Bewareof racial, ethnic and cultural pitfalls • Disclose news non-verbally through inference • Do not use phrases like: –“You have cancer” –“The cancer is incurable” • Ascertain the patient/family desires in advance
- 30. Breaking the Newsby Phone • This is not the preferred method • Ensure you are in a quiet place • Have sufficient time for the call • Ensure the patient is in a position to talk • Confirm the results • Anticipate emotional reactions/difficult questions • Provide information clearly and with sensitivity • Allow time for reaction
- 31. Breaking the Newsby Phone (Cont.) • Confirm their understanding of discussion • Offer support and sympathy • Provide followup procedures/contact information • If someone answers other than next of kin: – Determine relationship – Make effort to determine how to contact next of kin without creating alarm
- 32. What specific challenges doyou face?
- 33. Are you ready? Makesure you are prepared enough to break the news!
- 34. In Summary By discussingthe information sensitively and allowing the patient/family to take the lead on decision-making, you give the patient a measure of control in the process of receiving and accepting bad news
- 35. Closing If end-of-life careconversations are done poorly, patient and family members may never forgive us. However, if we do it well, they will never forget us!
- 36.